|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| Rubin et al. have approached the problem of longstanding, irreversible seventh-nerve paralysis by transferring portions of the temporalis, masseter, and frontal muscles to simulate facial nerve function.23-25 Such techniques can be effective in creating an immediate smile and lid closure but, as pointed out previously, these movements are not spontaneous and disappear with emotional response. Such techniques are also not possible when the fifth cranial nerve is involved after tumor removal and certain congenital syndromes such as Mobius. McLaughlin 26 described the technique for transferring the coronoid process with its temporalis insertion to the corner of the mouth. The McLaughlin procedure avoids the fullness in the zygomatic arch area produced by the Rubin turned-down temporalis muscle and also eliminates the need for prosthetic material to fill in the defect produced in the temporalis area when the origin of the muscle is divided. The anterior belly of the digastric has been advanced to produce lip depression, first described by Edgerton 27 and then modified by Conley et al., who turned over the anterior belly.28 Again, this muscle action must be learned; it is not spontaneous in nature.
A new approach to facial reanimation was made possible by Susumu Tamai's experimental work, which demonstrated that skeletal muscle could be transplanted by microneurovascular anastomosis.29 Harii applied this principle to facial paralysis by transplanting the gracilis to the paralyzed side of the face innervating it with motor branches from the masseter muscle.30 Although this approach produced strong contractions and a semblance of a smile, function still remained under fifth-nerve control. Others have shown experimentally that muscles can be transplanted into an area where no nerve exists and be reinnervated with long nerve grafts to more proximal or contralateral nerve sources.31 Harii again was the first to use these principles clinically by combining a crossfacial nerve graft with the gracilis muscle transplant in a two-stage procedure. 7,32 Others have used the serratus, 33 the pectoralis minor, 34 portions of the pectoralis major,35,36 the extensor brevis,37 the palmaris longus,38 and portions of the latissimus39,40 and gracilis41 as the muscle source.28,29 We prefer to use the lower three slips of the serratus 33 because of its anatomic conFIGuration and the location of the nerve and blood supply.
Our management of late facial paralysis is continually evolving as we evaluate our results and learn from the experience of others. A two-stage reconstruction is performed, with dynamic suspension and crossfacial grafting in the first stage, followed by a free serratus muscle transplantation. During the first operation, we perform the following:
1. The McLaughlin temporalis muscle transfer to the corner of the mouth and nasolabial folds.
2. A turndown of the anterior 20% of the temporalis muscle, extending its fascia to provide slings to the upper and lower eyelids.
3. An anterior belly digastric turnover to the lower lip.
4. A crossfacial nerve graft using the unparalyzed side marginal mandibular and a large branch to the zygomatic area.
5. A concomitant face and neck lift, as needed.
6. McLaughlin lateral tarsorrhaphy to tighten and support the paralyzed lower lid.
At the second operation, the following procedures are performed:
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